Provider-Patient Cost Conversations: The Untapped Contributor to Quality Care

By September 18, 2023 December 16th, 2023 News

Time and again research has shown that when medication costs increase, adherence decreases. But even though we have that knowledge—and we’re armed with tools to help us find lower-priced drugs—we’re not ensuring that information actually gets to patients.

As reported by the World Health Organization, adherence is a critical component in driving quality care and outcomes: It can have more impact on a patient’s outcomes than a specific treatment itself. CMS and other organizations have acknowledged this, creating measures and incentives to support a focus on medication adherence. For example, CMS has long included medication adherence measures in its annual Medicare Star Ratings calculations.

Yet despite the knowledge, regulations, and incentives, health systems and health plans continue to struggle with finding effective ways to drive medication adherence at scale. Traditional methods—including relying on staff to conduct massive amounts of personalized outreach to drive first fills and refills—leave tremendous room for improvement, as evidenced by the fact that one in five prescriptions are never filled. The challenge is acutely felt among burned-out pharmacists, providers, and care teams who want their patients to get better, but ultimately get caught up in hours of administrative re-work when patients can’t afford the originally prescribed medication.

With the rise of value-based care and risk-sharing agreements, ongoing workforce challenges (burned-out clinicians, staffing levels, and high labor costs), and the ever-increasing cost to the overall healthcare system, there has to be more urgency around solving the medication adherence challenge.

Solving for adherence starts by solving for affordability

There are multiple reasons people do not adhere to medications but cost consistently tops the list. The complexity of our healthcare system and insurance plan design makes it extremely hard to identify out-of-pocket costs without the use of technology. There is simply too much data for providers to collect and try to crunch themselves in the 15 minutes they have with each patient.

But that doesn’t mean we—the collective “we” as an industry—give up. Turning the other way and trying to solve for adherence without considering costs isn’t setting anyone up for success. That’s because patients who cannot afford medications are not going to take them. As a consequence, these patients experience poor outcomes: they show up with acute illness in the emergency room, get readmitted to the hospital, end up on dialysis or needing limbs amputated—all avoidable outcomes in many cases that are creating higher downstream costs for the whole system.

How talking about costs drives quality care

Proactively bringing cost into patient-provider conversations is an effective way to remove the number one barrier to adherence.

Using existing technology, providers can not only identify real-time costs based on individual patient factors (what plan they have, what medications are covered at that specific moment in time) for prescribed medications, but they can also see lower-cost alternatives, different fulfillment options, and even cash-pay/coupon options to help patients afford the medications they need. The key to driving adoption of these solutions is integrating them into the EHR, making the data accessible in workflow so providers don’t have to spend precious time and/or use multiple applications searching for affordable options.

The impact is immediate and meaningful. According to one provider, having access to real-time cost and coverage data felt like having a blindfold taken off, “Now I can see,” she said. Instead of blindly prescribing medications without knowing if patients can afford to pay for them, providers can use in-workflow tools to talk about costs with patients before they head to the pharmacy. If a medication is too expensive and they will not adhere, the provider can use the tool to find other medically viable options or ways to pay for the medication. Having this conversation up-front supports adherence, which in turn supports long-term outcomes. It also supports providers by boosting patient satisfaction, as well as reducing hours of administrative work due to re-prescribing.

Shifting the culture to make talking about healthcare costs routine

A patient who can afford their medications is more likely to take them. An adherent patient is more likely to have better outcomes. Better outcomes lead to less strain on the system and lower overall healthcare costs. With these facts, it’s clear that we need to make talking about costs a common occurrence in the exam room, just like taking your temperature.

We can accelerate change by making it easier for providers and patients to access accurate, real-time cost and coverage data – so the right prescription is ordered the first time. Arrive Heath is doing this by helping innovative health systems use technology to change the outcome. Our EHR-integrated solutions give providers access to patient-specific, moment-in-time cost and coverage data in seconds, leading to reductions in monthly out-of-pocket costs and savings in the hundreds of dollars for some patients.